Emilio Vincenzo Dovellini

Relation between preintervention angiographic evidence of coronary collateral circulation and clinical and angiographic outcomes after primary angioplasty or stenting for acute myocardial infarction

It is unknown if collateral circulation (CC) has a beneficial effect on outcomes of patients who undergo mechanical intervention in the first hours after onset of acute myocardial infarction (AMI). This study analyzes the relation between CC and outcome in patients with AMI who underwent primary angioplasty or stenting within 6 hours of symptom onset. The analysis was performed in a series of 1,164 consecutive patients. The contribution of clinical, angiographic, and procedural variables to the angiographic and clinical outcomes was evaluated by multivariate logistic regression analysis and the Cox proportional hazard model, respectively. Of 1,164 patients, 264 (23%) had angiographic evidence of CC. Patients with CC had a lower incidence of diabetes (11% vs 16%, p = 0.033), anterior AMI (41% vs 55%, p <0.001), cardiogenic shock (9% vs 14%, p = 0.029), anterograde TIMI grade flow >1 (10% vs 21%, p <0.001), and a greater incidence of preinfarction angina (43% vs 32%, p = 0.001), multivessel disease (59% vs 47%, p = 0.001), and total chronic occlusion (20% vs 10%, p <0.001). At 6 months, the mortality rate was lower in patients with CC compared with patients without CC (4% vs 9%, p = 0.011), whereas there were no differences in the incidence of reinfarction, target vessel revascularization, and angiographic restenosis. After multivariate analysis, CC did not emerge as a significant variable in relation to 6-month clinical and angiographic outcomes. CC does not exert a protective effect in patients who undergo mechanical intervention in the first 6 hours of AMI onset.

Prognostic implications of restrictive left ventricular filling in reperfused anterior acute myocardial infarction

OBJECTIVES We sought to assess the relative prognostic role of a restrictive left ventricular (LV) filling pattern after a first anterior acute myocardial infarction (AMI) in patients treated with primary percutaneous transluminal coronary angioplasty (PTCA). BACKGROUND In thrombolized patients, a short Doppler-derived mitral deceleration time (DT) of early filling is a powerful independent predictor of heart failure and death. However, it is still unknown whether the outcome of patients with AMI with a short DT may be improved by a more aggressive treatment. METHODS In 104 patients, two-dimensional and Doppler echocardiograms were obtained three days after the index AMI. Coronary angiography was performed in all patients one and six months after PTCA. The patients were classified into two groups according to the DT duration: group 1 (n = 34) with DT < or = 130 ms and group 2 (n = 70) with DT >130 ms. All patients were followed-up for a mean (+/- SD) period of 32 +/- 10 months. RESULTS During the follow-up period, 14 patients (13%) were admitted to the hospital for congestive heart failure, and 9 patients (9%) died. All cardiac deaths (n = 7) occurred in group 1. The survival rate at mean follow-up was 79% in group 1 and 97.2% in group 2 (p = 0.003). Multivariate Cox analysis showed that only age and restrictive filling were independent predictors of event-free survival. Furthermore, when survival with no cardiovascular events was analyzed, a short DT still emerged as the most powerful independent predictor. CONCLUSIONS Patients with a restrictive LV filling pattern early after anterior AMI have a poor clinical outcome, even if treated with primary PTCA.

Predictors of Reocclusion After Successful Drug-Eluting Stent–Supported Percutaneous Coronary Intervention of Chronic Total Occlusion

OBJECTIVES This study sought to assess the incidence of reocclusion and identification of predictors of angiographic failure after successful chronic total occlusion (CTO) drug-eluting stent-supported percutaneous coronary intervention (PCI). BACKGROUND Large registries have shown a survival benefit in patients with successful CTO PCI. Intuitively, sustained vessel patency may be considered as a main variable related to long-term survival. Very few data exist about the angiographic outcome after successful CTO PCI. METHODS The Florence CTO PCI registry started in 2003 and included consecutive patients treated with drug-eluting stents for at least 1 CTO (>3 months). The protocol treatment included routine 6- to 9-month angiographic follow-up. Clinical, angiographic, and procedural variables were included in the model of multivariable binary logistic regression analysis for the identification of the predictors of reocclusion. RESULTS From 2003 to 2010, 1,035 patients underwent PCI for at least 1 CTO. Of these, 802 (77%) had a successful PCI. The angiographic follow-up rate was 82%. Reocclusion rate was 7.5%, whereas binary restenosis (>50%) or reocclusion rate was 20%. Everolimus-eluting stents were associated with a significantly lower reocclusion rate than were other drug-eluting stents (3.0% vs. 10.1%; p = 0.001). A successful subintimal tracking and re-entry technique was associated with a 57% of reocclusion rate. By multivariable analysis, the subintimal tracking and re-entry technique (odds ratio [OR]: 29.5; p < 0.001) and everolimus-eluting stents (OR: 0.22; p = 0.001) were independently related to the risk of reocclusion. CONCLUSIONS Successful CTO-PCI supported by everolimus-eluting stents is associated with a very high patency rate. Successful subintimal tracking and re-entry technique is associated with a very low patency rate regardless of the type of stent used.

Sex-based differences in clinical and angiographic outcomes after primary angioplasty or stenting for acute myocardial infarction.

A paucity of data exists on the importance of gender in contributing to the mortality rate after primary angioplasty, although it is has been shown that women with acute myocardial infarction (AMI) are less likely than men to undergo reperfusion treatments. This study analyzes gender-related differences in 6-month clinical and angiographic outcomes in nonselected patients with AMI who underwent primary angioplasty or stenting. We compared clinical and angiographic outcomes of 230 women and 789 men who underwent primary angioplasty or stenting from January 1995 to August 1999. The women were older than the men, and had a greater incidence of diabetes and cardiogenic shock. The 6-month mortality rate was 12% in women and 7% in men (p = 0.028). Nonfatal reinfarction occurred in 3% of the women and in 1% of the men (p = 0.010). There were no differences in repeat target vessel revascularization rates. After multivariate analysis, gender did not emerge as a significant variable in relation to 6-month mortality or to the combined end point of death, reinfarction, and repeat target vessel revascularization. Both women and men with stented infarct arteries had lower restenosis rates (29% and 26%, respectively) than patients without stents (52% and 39%, repectively). The results of outcome analysis in nonselected patients suggest that sex is not an independent predictor of mortality after primary angioplasty for AMI, and that the benefit of primary stenting is similar in men and women.

Abciximab therapy improves survival in patients with acute myocardial infarction complicated by early cardiogenic shock undergoing coronary artery stent implantation

The impact of abciximab therapy on mortality in patients with acute myocardial infarction (AMI) who are undergoing infarct-related artery (IRA) stent implantation, which is complicated by cardiogenic shock (CS) due to predominant ventricular failure has not been established, whereas concluded randomized trials comparing IRA stenting plus abciximab with IRA stenting alone in patients with AMI have produced conflicting results. Moreover, these trials have excluded patients with CS from randomization. This study sought to determine whether IRA stenting plus abciximab treatment has an impact on 1-month mortality compared with IRA stenting alone in consecutive patients with AMI complicated by CS due to predominant ventricular failure. Of 77 patients with CS and IRA stenting, 44 had abciximab therapy, whereas 33 underwent primary IRA stenting alone. There were no differences between groups in major baseline characteristics except for a higher incidence of women in the stent alone group compared with the abciximab group (36% vs 14%, p = 0.020). The 1-month overall mortality rate was 18% in the abciximab group and 42% in the stent alone group (p <0.020). There were no differences between groups in reinfarction and target vessel revascularization rates. Multivariate analysis showed that abciximab therapy was the only variable that was independently related to 1-month mortality (odds ratio 0.36; 95% confidence intervals 0.15 to 0.86, p = 0.021). The results of this study support the use of abciximab in patients with AMI complicated by CS who are undergoing IRA stent implantation. The mechanism of the clinical benefit of abciximab at 1 month was not related to the patency of the IRA.

Early short-term doxycycline therapy in patients with acute myocardial infarction and left ventricular dysfunction to prevent the ominous progression to adverse remodelling: the TIPTOP trial

AIMS Experimental studies suggest that doxycycline attenuates post-infarction remodelling and exerts protective effects on myocardial ischaemia/reperfusion injury. However, the effects of the drug in the clinical setting are unknown. The aim of this study was to examine the effect of doxycycline on left ventricular (LV) remodelling in patients with acute ST-segment elevation myocardial infarction (STEMI) and LV dysfunction. METHODS AND RESULTS Open-label, randomized, phase II trial. Immediately after primary percutaneous coronary intervention, patients with STEMI and LV ejection fraction < 40% were randomly assigned to doxycycline (100 mg b.i.d. for 7 days) in addition to standard therapy, or to standard care. The echo LV end-diastolic volumes index (LVEDVi) was determined at baseline and 6 months. (99m)Tc-Sestamibi-single-photon emission computed tomography infarct size and severity were assessed at 6 months. We calculated a sample size of 110 patients, assuming that doxycycline may reduce the increase in the LVEDVi from baseline to 6 months > 50% compared with the standard therapy (statistical power > 80% with a type I error = 0.05). The 6-month changes in %LVEDVi were significant smaller in the doxycycline group than in the control group [0.4% (IQR: -16.0 to 14.2%) vs.13.4% (IQR: -7.9 to 29.3%); P = 0.012], as well as infarct size [5.5% (IQR: 0 to 18.8%) vs. 10.4% (IQR: 0.3 to 29.9%) P = 0.052], and infarct severity [0.53 (IQR: 0.43-0.62) vs. 0.44 (IQR: 0.29-0.60), P = 0.014], respectively. CONCLUSION In patients with acute STEMI and LV dysfunction, doxycycline reduces the adverse LV remodelling for comparable definite myocardial infarct size (NCT00469261).

Drug-eluting stent supported percutaneous coronary intervention for unprotected left main disease

Objectives: This study sought to determine the clinical and angiographic outcomes of unselected patients receiving drug‐eluting stents for unprotected left main disease. Background: The results of several series of percutaneous coronary intervention (PCI) for left main disease in the pre‐drug‐eluting stent era have arisen concerns on the safety and mid‐term efficacy of PCI. Methods: Consecutive patients with unprotected left main disease were considered eligible for drug‐eluting stent supported PCI. The surgical risk score (risk of death within 1 month) of each patient was calculated according to the European System for Cardiac Operative Risk Evaluation (EuroSCORE) model. Results: One‐hundred and one patients with unprotected left main disease underwent PCI. The mean EuroSCORE was 19 ± 23. Successfully left main stenting was performed in 98 patients (primary success rate 97%). The overall 1‐month mortality rate was 9.9%. The 1‐month mortality rate was 50% in patients with acute myocardial infarction (AMI) on presentation, and 4.5% in patients without AMI on presentation. The 1‐month mortality rate of patients with a risk score <13 was 3%, while it was 21% in patients with a risk score ≥13. At 6 months, the mortality rate of the entire cohort of patients increased to 12.8%, and the one of the non‐AMI patients to 7.8%. Survival rate was 86% ± 4% (mean follow‐up 295 ± 175 days). Target vessel revascularization was performed in 14 patients (16%). The 6‐month in‐segment restenosis rate was 16%. Conclusion: Drug‐eluting stent supported PCI may provide early and mid‐term outcomes comparable or superior to those expected from coronary artery surgery.

Clinical and Angiographic Outcomes of Patients Treated With Everolimus-Eluting Stents or First-Generation Paclitaxel-Eluting Stents for Unprotected Left Main Disease

OBJECTIVES The goal of this study was to compare the outcomes of patients treated with everolimus-eluting stents (EES) with outcomes of patients treated with first-generation paclitaxel-eluting stents (PES) for unprotected left main disease (ULMD). BACKGROUND No data exist about the comparison of these 2 types of stents in ULMD. METHODS The primary endpoint of the study was a 1-year composite of cardiac death, nonfatal myocardial infarction, target vessel revascularization, and stroke (MACE). Secondary endpoints were 1-year target vessel failure (TVF) and 9-month angiographic in-segment restenosis >50%. RESULTS From 2004 to 2010, a total of 390 patients underwent ULMD percutaneous coronary intervention (224 received PES and 166 EES). The 1-year MACE rate was 21.9% in the PES group and 10.2% in the EES group (p = 0.002). TVF rate was 20.5% in the PES group and 7.8% in the EES group (p < 0.001). The in-segment restenosis rate was 5.2% in the EES group and 15.6% in the PES group (p = 0.002). EES and EuroSCORE were the only variables related to the risk of MACE. EES (odds ratio: 0.32; p = 0.007) was also independently related to the risk of restenosis. CONCLUSIONS EES implantation for ULMD is associated with a reduced incidence of 1-year MACE, TVF, and restenosis as compared with PES implantation.

Heart Failure and Left Ventricular Remodeling After Reperfused Acute Myocardial Infarction in Patients With Hypertension

In the thrombolytic era, hypertension has been shown to adversely affect the development of heart failure after acute myocardial infarction (AMI). We sought to examine the relation between antecedent hypertension and heart failure after mechanical reperfusion and to test the impact of postinfarction left ventricular remodeling on heart failure in hypertensive patients. A series of 953 patients (324 hypertensives) with AMI treated with successful primary percutaneous coronary intervention underwent a 5-year follow-up. A subgroup of 325 subjects underwent 2D echocardiography at admission, 1 month, and 6 months. From day 1 to 6 months, despite similar improvement in regional and global left ventricular function and similar 6-month infarct artery patency rate, left ventricular end-diastolic volume increased in the normotensives (122±36 mL to 131±47 mL; P<0.001) but not in the hypertensives (127±41 mL to 128±31 mL; P=0.768). At 6 months, the incidence of left ventricular remodeling in hypertensive and normotensive patients was not different (22% versus 28%; P=0.210). However, at 5 years, the incidences of hospitalization for heart failure (7% versus 3%; P=0.014) and of New York Heart Association functional class ≥2 (53% versus 40%; P<0.001) were higher in hypertensive as compared with normotensive patients. Hypertension was found to be a predictor of heart failure (hazard ratio, 2.23; P=0.015). In conclusion, patients with antecedent hypertension are at higher risk to develop heart failure after AMI, even when successfully reperfused by primary percutaneous coronary intervention. However, the increased incidence of heart failure in hypertensive patients is not associated with a greater propensity to postinfarction left ventricular remodeling.

Percutaneous reperfusion of left main coronary disease complicated by acute myocardial infarction

Previous studies have shown a benefit of a strategy of direct angioplasty and stenting in patients with acute myocardial infarction (AMI) complicated by early cardiogenic shock. However, few data exist for the subset of patients with left main trunk disease complicated by AMI and cardiogenic shock. We performed an analysis of patients with AMI who underwent mechanical intervention between January 1995 and December 2000. Out of 1,433 patients with ST segment elevation AMI treated with primary coronary angioplasty (PTCA), 22 patients (1.5%) had left main disease (LMD) as the culprit lesion. Baseline characteristics were age, 66 ± 11 years; female gender, 9%; diabetes, 14%; previous myocardial infarction, 14%; mean systolic blood pressure, 77 ± 24 mm Hg; time to treatment, 4.8 ± 2.2 hr; TIMI 0–1, 77%; collateral flow (Rentrop grade ≥ 2) 9%. The primary success rate was 91%. Primary stenting was performed in 17 patients (77%). The in‐hospital mortality rate was 50%. All deaths were due to refractory shock. The 6‐month survival rate was 41% ± 1%, while the event‐free survival rate was 27% ± 10%. At 6‐month follow‐up, the mortality rate increased to 59%; the target vessel revascularization rate was 14%. A percutaneous mechanical intervention strategy in patients with left main disease complicated by AMI is feasible and effective, and patients discharged alive have a good mid‐term prognosis. Cathet Cardiovasc Intervent 2002;56:31–34.